Chapter 12.1

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Across
  1. 4. observations based on feelings or opinions
  2. 5. legal document that records what happens to a patient
  3. 6. The storage and remembrance of past experience
  4. 7. the process of gathering and measuring information
  5. 9. give a spoken or written account of something that one has observed, heard, or done
  6. 12. observing someone (or something) carefully in order to gain information
  7. 13. information collected based on the senses that is used to document; sight, hearing, touch, smell
Down
  1. 1. 24-hour clock that begins at midnight. Used to avoid confusion between am & pm hours
  2. 2. information collected used to document based on personal opinion, judgement, feelings, or point of view
  3. 3. clear, accurate method of keeping track of everything that happens to a patient
  4. 6. Written account of a person’s health history. Includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
  5. 8. Electronic medical record; component of EHR which includes information about a patient’s single stay in a facility
  6. 10. observations based on facts
  7. 11. a written plan of care based on a comprehensive assessment; provides guidance for delivering individualized and consistent care
  8. 14. Electronic health record; contains a person’s specific health information in one place